Differential Diagnosis for Acute Ataxia

Given the patient's presentation of acute ataxia and the finding of senescent calcifications in the basal ganglia on CTA of the head, the following differential diagnoses are considered:

• Single Most Likely Diagnosis

  • Vascular Event (Stroke): Although senescent calcifications themselves are not typically associated with acute symptoms, the presence of such calcifications in the basal ganglia could be a marker for underlying vascular disease. A vascular event, such as a stroke, could cause acute ataxia. The Romberg sign might be positive if the ataxia affects the patient's balance and proprioception.

• Other Likely Diagnoses

  • Multiple Sclerosis: Demyelinating diseases like multiple sclerosis can present with acute ataxia. While the basal ganglia calcifications are not directly related, MS can affect various parts of the CNS, potentially leading to ataxia. Romberg sign could be positive depending on the lesion's location.
  • Vitamin B12 Deficiency: A deficiency in vitamin B12 can lead to subacute combined degeneration of the spinal cord, presenting with ataxia among other symptoms. The Romberg sign could be positive due to the involvement of the dorsal columns.

• Do Not Miss Diagnoses

  • Posterior Circulation Stroke: This is a critical diagnosis not to miss, as it can have severe consequences if not promptly treated. The symptoms can include acute ataxia, and the Romberg sign might be positive. Although the calcifications in the basal ganglia are not directly indicative of this, any new neurological deficit warrants thorough investigation.
  • Cerebellar Hemorrhage: A hemorrhage in the cerebellum can cause sudden onset ataxia. While the basal ganglia calcifications are not directly related, the possibility of a hemorrhagic stroke, especially in the context of acute ataxia, must be considered and ruled out with imaging. The Romberg sign could be positive.

• Rare Diagnoses

  • Creutzfeldt-Jakob Disease: This is a rare, degenerative, fatal brain disorder that can present with ataxia among its initial symptoms. The Romberg sign could be positive. While it's rare, its rapid progression and fatal outcome make it a diagnosis to consider in the appropriate clinical context.
  • Ataxia Telangiectasia: A rare genetic disorder that affects the nervous system, immune system, and other bodily systems. It could present with progressive ataxia, but its acute presentation would be unusual. The Romberg sign is typically positive in patients with ataxia telangiectasia due to the significant cerebellar involvement.